Prior Authorization Required

Prior authorization is required for review of procedures when submitting any of the listed CPT codes. Use the specific CPT codes in the Coding section when requesting prior authorization and include all supporting operative and clinical documentation to facilitate review.

• Submit prior authorization request before the procedure date
• Include the exact CPT codes from the coding table when requesting review
• Attach operative plan and planned CPT codes if requesting pre-service review

Clinical Documentation to Support Reconstructive Indication

Document a complete clinical history that supports a reconstructive (functional) indication rather than cosmetic-only intent. Clinical documentation should describe how excess skin/fat produces functional impairment and prior conservative measures tried.

• Describe history of massive weight loss (including cause, magnitude and timing)
• Note location and extent of redundant skin and subcutaneous tissue (eg, abdomen, waist, hips, back, buttocks, breasts, arms, medial thighs)
• Document specific functional signs or symptoms such as intertrigo, recurrent skin infections, ulceration, difficulty with hygiene, interference with activities of daily living, chronic rashes in skin folds, or limitations in mobility
• Include physical exam findings demonstrating overhanging panniculus or redundant tissue causing contact dermatitis or maceration
• Attach photographs when available to demonstrate anatomic impairment and correlate with clinical findings

Cosmetic-only Procedures Not Covered

Procedures performed solely to improve appearance without documented functional signs or symptoms are considered cosmetic and are not covered.

• If the procedure addresses only appearance without documented functional impairment, it will be considered cosmetic-only and not compensable
• When a circumferential procedure treats both functional anterior abdomen and cosmetic posterior areas, only the anterior portion addressing functional impairment is considered reconstructive; posterior portions are cosmetic

Provider Documentation Checklist

Provide all operative notes, pre-operative and post-operative evaluations, and any conservative treatment records when submitting for prior authorization or claim review to avoid delays or denials.

• Include prior conservative management (e.g., medical therapy, topical treatments, hygiene measures) and response
• Supply documentation tying CPT codes requested to the reported clinical findings and planned procedures
• Use listed CPT codes when requesting review and provide supporting documentation